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Waste Tire Su*y & Inspection Report Inspection Report Number ■ <br /> State of California <br /> I Survey Form - Page 1 i - 10 4 $ 59 <br /> CIWMB 181 New 04/04 <br /> California Integrated Waste Management Board <br /> = Part A- Survey _ BLUE OR BLACK INK PEN <br /> 't'{}z�•�`;�r, art'� w,w "`�,„�«� � ,, �"m;r< ,cue ,,�"E;nrw,� w.� ,;: , �,�r cry i e.= u�. n r.r�•' rJ ,yr w i r <br /> F TPID- - I Inspection Type (Fill one) <br /> `bite Suffix: o - �( ( Routine 0 Re inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> tifie <br /> Idenr: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 7 - <br /> I - Inspected By Inspector <br /> Physlaall Address <br /> �;.•-•--� Inspection Date <br /> , Cit <br />' Y Stat �P Code Time In _ Time Out <br /> Business Rep Title ff Q AM Q AM <br /> QPM QPM <br /> L <br /> f'Operational Status I � a "N� Business Role <br /> Fill one only) o f i Fill all that apply) <br /> CJ )a ( �tlI ( <br /> (a Active s t1 $t '' Q Generator <br /> 0 Closed <br /> S Latitude <br /> �a�A Hauler <br /> f "ar rr <br /> d,1 <br /> . _ 0 inactive <br /> f," {".,. w ✓;rl'/r�" ,�+tiyti" }"J " / "" <br /> Longitude - 0 Planned 0 End- <br /> 0 <br /> nd 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STAT S <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 @PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Compliance' <br /> m te Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle p <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m, LE <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- - -- <br /> 0 @ 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred(CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 In Compliance - Na Violations <br /> 0 0 Other: <br /> Comments <br /> Pf <br /> 55 <br /> Q,: .�.„ <br /> INSTRUCTIONS ON BACK [Correct: Incorrect (�)"'(�,,1 A M P ' 1 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />